BACKFLOW Prevention Device Inspection and Maintenance Report

• Site conducted

  Select

PROPERTY DETAILS

• Test report

  Backflow device test report

  other

• Test report number

• Site address
  Address

Test type

• What type of test is being performed

  Annual

  Commissioning

  Audit inspection

  Re test

  Other

Location of backflow prevention device

• Where in the property is the device located

DEVICE INFORMATION

• What is the device servicing

  Select Domestic water Fire Hydrant service Fire sprinkler service Fire hose reel Dirty utilities room Irrigation system Medical equipment Mechanical plant Hose tap at grease arrestor Hose tap in bin room Other

  • Domestic water
  • Fire Hydrant service
  • Fire sprinkler service
  • Fire hose reel
  • Dirty utilities room
  • Irrigation system
  • Medical equipment
  • Mechanical plant
  • Hose tap at grease arrestor
  • Hose tap in bin room
  • Other

• What is the water meter number?

• Device type

  Select

• Manufacturer

• Size

  Select

• Model

• Serial number

• Provide photo of the device being tested with test gauge connected

  Media

• Provide photo of device serial number

  Media

• By-pass water meter number

• By-pass water meter reading

• Is there a strainer installed

  Yes

  No

  N/A

Test

• Check Valve Number One

  Tight

  Leaked

• Differential Pressure (kpa)

• Check Valve Number Two

  Tight

  Leaked

• Differential Pressure (kpa)

• Relief port opened at (kpa) Only required if RPZD

• By-pass Check Valve Number One

  Tight

  Leaked

• Differential Pressure (kpa)

• By-pass Check Valve Number Two

  Tight

  Leaked

• Differential Pressure (kpa)

• By-pass Relief port opened at (kpa) Only required if RPZD

• Downstream Isolation Valve

  Tight

  Leaked

• Valve Required Repair/Part Replacement:

  Yes

  No

• Device test result

  Pass

  Fail

  N/A

Test Kit Details

• Test Kit Number: TK-9A Serial No: 110081

• Test Kit Certification Date Of Calibration: 5th December 2022

Contractor Details

• Contractor: Holland Bros Plumbing
  Mail: 2/14 Chicago Ave Blacktown
  Email: info@hollandbrosplumbing.com.au
  Phone: 02 9764 2790
  Licence: 223351C

• I certify that I have completed the required training & hold the required certifications to undertake Backflow Testing & Commissioning. Based upon these certifications I can declare that this device meets the performance requirements of AS2845

• Testers Name:

  Select

• Add signature

  Sign

• Test performed on

  Date

• Comments